RCUH Policies and Procedures
Kaiser Permanente Senior Advantage (HMO) Group plan
With Medicare Part D prescription drug coverage
About this Summary of Benefits
Thank you for considering Kaiser Permanente Senior Advantage. You can use this Summary of
Benefits to learn more about our plan. It includes information about:
• Benefits and costs
• Part D prescription drugs
• Who can enroll
• Coverage rules
• Getting care
For definitions of some of the terms used in this booklet, see the glossary at the end.
For more details
This document is a summary. It doesn’t include everything about what’s covered and not covered
or all the plan rules. For details, see the Evidence of Coverage (EOC), which we’ll send you after you
enroll. If you’d like to see it before you enroll, please ask your group benefits administrator for a copy.
Have questions?
• Please call Member Services at 1-800-805-2739 (TTY 711).
• 7 days a week, 8 a.m. to 8 p.m.
Summary of Benefits
Kaiser Permanente Senior Advantage is a Medicare Advantage Health Maintenance
Organization (HMO) plan offered by Kaiser Foundation Health Plan of Hawaii.
This document is a summary and does not include all plan rules, benefits, limitations, and exclusions.
For complete details, please refer to the Evidence of Coverage (EOC), which we will send you after
you enroll. If you would like to review the EOC before you enroll, please ask your group benefits
administrator for a copy.
Please see the attached Kaiser Permanente Senior Advantage benefit chart for benefits you receive
through your employer or trust fund.
Medicare Part D prescription drug coverage†
The amount you pay for drugs will be different depending on:
• The tier your drug is in. There are 6 drug tiers. To find out which of the 6 tiers your drug is in,
see our Part D formulary at kp.org/seniorrx or call Member Services to ask for a copy at
1-800-805-2739 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.
• The day supply quantity you get (like a 30-day or 90-day supply). Note: A supply greater
than a 30-day supply isn’t available for all drugs.
• When you get a 31- to 90-day supply, whether you get your prescription filled by one of
our retail plan pharmacies or our mail-order pharmacy. Note: Not all drugs can be mailed.
• The coverage stage you’re in (deductible, initial, coverage gap, or catastrophic coverage
stages).
Please see the enclosed Kaiser Permanente Senior Advantage benefit chart for your group’s
prescription drug coverage.
Deductible stage
Because we have no deductible, this payment stage does not apply to you and you start the year in
the initial coverage stage.
Initial coverage stage
If your group plan includes a Coverage Gap, you pay the copays and coinsurance shown in the
attached prescription drug coverage chart until your total yearly drug costs reach $4,430. (Total yearly
drug costs are the amounts paid by both you and any Part D plan during a calendar year.) If you reach
the $4,430 limit in 2022, you move on to the coverage gap stage and your coverage changes. Please
see the “Medical Benefits Chart” (what is covered and what you pay)”, Chapter 5, and Chapter 6 in the
Evidence of Coverage (EOC).
If your group plan does not include a Coverage Gap, you pay the copays and coinsurance shown in
the attached prescription drug coverage chart until you have spent $7,050 in 2022. If you spend
$7,050 in 2022, you move on to the catastrophic coverage stage and your coverage changes.
Catastrophic coverage stage
If you spend $7,050 on your Part D prescription drugs in 2022, you’ll enter the catastrophic coverage
stage. Most people never reach this stage, but if you do, your copays and coinsurance will change for
the rest of 2022. Please see the “Medical Benefits Chart” (what is covered and what you pay)”,
Chapter 5, and Chapter 6 in the Evidence of Coverage (EOC).
Long-term care, plan home-infusion, and non-plan pharmacies
• If you live in a long-term care facility and get your drugs from their pharmacy, you pay
the same as at a retail plan pharmacy and you can get up to a 31-day supply.
• Covered Part D home infusion drugs from a plan home-infusion pharmacy are provided
at no charge.
• If you get covered Part D drugs from a non-plan pharmacy, you pay the same as at a
retail plan pharmacy and you can get up to a 30-day supply. Generally, we cover drugs
filled at a non-plan pharmacy only when you can’t use a network pharmacy, like during
a disaster. See the Evidence of Coverage for details.
Who can enroll
You can sign up for this plan if:
• You are enrolled in Kaiser Permanente through your group plan and meet your group’s
eligibility requirements.
• You have both Medicare Part A and Part B. (To get and keep Medicare, most people must pay
Medicare premiums directly to Medicare.)
• You’re a citizen or lawfully present in the United States.
• You live in the service area for this plan, which includes all of Honolulu County. Also, our
service area includes these parts of the following counties:
o Maui County, in the following ZIP codes only: 96708, 96713, 96732, 96733, 96753,
96761, 96767, 96768, 96779, 96784, 96788, 96790, and 96793.
o Hawaii County, in the following ZIP codes only: 96704, 96710, 96719, 96720, 96721,
96725, 96726, 96727, 96728, 96737, 96738, 96739, 96740, 96743, 96745, 96749,
96750, 96755, 96760, 96764, 96771, 96773, 96774, 96776, 96778, 96780, 96781,
96783, and 96785.
Coverage rules
We cover the services and items listed in this document and the Evidence of Coverage, if:
• The services or items are medically necessary.
• The services and items are considered reasonable and necessary according to Original
Medicare’s standards.
• You get all covered services and items from plan providers listed in our Provider Directory
and Pharmacy Directory. But there are exceptions to this rule. We also cover:
o Care from plan providers in another Kaiser Permanente Region
o Emergency care
o Out-of-area dialysis care
o Out-of-area urgent care (covered inside the service area from plan providers and
in rare situations from non-plan providers)
o Referrals to non-plan providers if you got approval in advance (prior authorization)
from our plan in writing
Note: You pay the same plan copays and coinsurance when you get covered care listed
above from non-plan providers. If you receive non-covered care or services, you must pay the
full cost.
For details about coverage rules, including non-covered services (exclusions), see the Evidence of
Coverage.
Getting care
At most of our plan facilities, you can usually get all the covered services you need, including
specialty care, pharmacy, and lab work. You aren’t restricted to a particular plan facility or
pharmacy, and we encourage you to use the plan facility or pharmacy that will be most
convenient for you. To find our provider locations, see our Provider Directory or Pharmacy
Directory at kp.org/directory or ask us to mail you a copy by calling Member Services at
1-800-805-2739, 7 days a week, 8 a.m. to 8 p.m. (TTY 711).
The formulary, pharmacy network, and/or provider network may change at any time.
You will receive notice when necessary.
Your personal doctor
Your personal doctor (also called a primary care physician) will give you primary care and will help
coordinate your care, including hospital stays, referrals to specialists, and prior authorizations.
Most personal doctors are in internal medicine or family practice. You must choose one of our
available plan providers to be your personal doctor. You can change your doctor at any time and for
any reason. You can choose or change your doctor by calling Member Services or at kp.org.
Help managing conditions
If you have more than 1 ongoing health condition and need help managing your care, we can help.
Our case management programs bring together nurses, social workers, and your personal doctor
to help you manage your conditions. The program provides education and teaches self-care skills.
If you’re interested, please ask your personal doctor for more information.
Notices
Appeals and grievances
You can ask us to provide or pay for an item or service you think should be covered. If we say no,
you can ask us to reconsider our decision. This is called an appeal. You can ask for a fast decision
if you think waiting could put your health at risk. If your doctor agrees, we’ll speed up our decision.
If you have a complaint that’s not about coverage, you can file a grievance with us. See the
Evidence of Coverage for details about the processes for making complaints and making coverage
decisions and appeals, including fast or urgent decisions for drugs, services, or hospital care.
Kaiser Foundation Health Plan
Kaiser Foundation Health Plan, Inc., Hawaii Region is a nonprofit corporation and a Medicare
Advantage plan called Kaiser Permanente Senior Advantage.
Language assistance services
ATTENTION: If you speak a language other than English, language assistance services, free of
charge, are available to you. Call 1-800-805-2739 (TTY: 711).
Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-800-805-2739 (TTY: 711).
Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-805-2739
(TTY: 711)
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho
bạn. Gọi số 1-800-805-2739 (TTY: 711).
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
tulong sa wika nang walang bayad. Tumawag sa 1-800-805-2739 (TTY: 711).
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-805-2739 (TTY: 711)번으로 전화해 주십시오.
Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
1-800-805-2739（TTY:711）まで、お電話にてご連絡ください。
Lao: ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວົ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ ວຍເຫຼື ອດ້ ານພາສາ, ໂດຍບໍ່
ເສັ ຽ
ຄ່ າ, ແ່ ມີນມພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-800-805-2739 (TTY: 711).
Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan
bayadna, ket sidadaan para kenyam. Awagan ti 1-800-805-2739 (TTY: 711).
Samoan: MO LOU SILAFIA: Afai e te tautala Gagana fa’a Sāmoa, o loo iai auaunaga fesoasoan, e
fai fua e leai se totogi, mo oe, Telefoni mai: 1-800-805-2739 (TTY: 711).
Marshallese: LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk
wōṇāān. Kaalọk 1-800-805-2739 (TTY: 711)
Trukese: MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe
angei aninisin chiakku, ese kamo. Kori 1-800-805-2739 (TTY: 711).
Hawaiian: E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo, loaʻa ke kōkua manuahi iā ʻoe.
E kelepona iā 1-800-805-2739 (TTY: 711).
Pohnpeian: Ni songen mwohmw ohte, komw pahn sohte anahne kawehwe mesen nting me
koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn
Pohnpei. Call 1-800-805-2739 (TTY: 711).
Bisayan: ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa
tabang sa lengguwahe, nga walay bayad. Tawag sa 1-800-805-2739 (TTY: 711).
Tongan: FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai
atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-800-805-2739 (TTY: 711)
Notice of nondiscrimination
Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not
exclude people or treat them differently because of race, color, national origin, age, disability,
or sex. We also:
• Provide no cost aids and services to people with disabilities to communicate effectively
with us, such as:
o Qualified sign language interpreters.
o Written information in other formats, such as large print, audio, and accessible
electronic formats.
• Provide no cost language services to people whose primary language is not English,
such as:
o Qualified interpreters.
o Information written in other languages.
If you need these services, call Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m.,
seven days a week.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way
on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil
Rights Coordinator by writing to 711 Kapiolani Blvd, Honolulu, HI 96813 or calling Member Services at
the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance,
our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue
SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Privacy
We protect your privacy. See the Evidence of Coverage or view our Notice of Privacy Practices
on kp.org/privacy to learn more.
Helpful definitions (glossary)
Benefit period
The way our plan measures your use of skilled nursing facility services. A benefit period starts the day you go into a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t gotten any inpatient hospital care or skilled care in an SNF for 60 days in a row. The benefit period isn’t tied to a calendar year. There’s no limit to how many benefit periods you can have or how long a benefit period can be.
Calendar year
The year that starts on January 1 and ends on December 31.
Coinsurance
A percentage you pay of our plan’s total charges for certain services or prescription drugs. For
example, a 20% coinsurance for a $200 item means you pay $40.
Copay
The set amount you pay for covered services — for example, a $20 copay for an office visit.
Deductible
It’s the amount you must pay for Medicare Part D drugs before you will enter the initial coverage stage.
Evidence of Coverage
A document that explains in detail your plan benefits and how your plan works.
Maximum out-of-pocket responsibility
The most you’ll pay in copays or coinsurance each calendar year for services that are subject to
the maximum. If you reach the maximum, you won’t have to pay any more copays or coinsurance
for services subject to the maximum for the rest of the year.
Medically necessary
Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your
medical condition and meet accepted standards of medical practice.
Non-plan provider
A provider or facility that doesn’t have an agreement with Kaiser Permanente to deliver care to
our members.
Plan
Kaiser Permanente Senior Advantage.
Plan provider
A plan or network provider can be a facility, like a hospital or pharmacy, or a health care
professional, like a doctor or nurse.
Prior authorization
Some services or items are covered only if your plan provider gets approval in advance from our
plan (sometimes called prior authorization). Services or items subject to prior authorization are
flagged with a † symbol in this document.
Region
A Kaiser Foundation Health Plan organization. We have Kaiser Permanente Regions located in
Northern California, Southern California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia,
Washington, and Washington, D.C.
Retail plan pharmacy
A plan pharmacy where you can get prescriptions. These pharmacies are usually located at plan
medical offices.Service area
The geographic area where we offer Senior Advantage plans. To enroll and remain a member of
our plan, you must live in one of our Senior Advantage plan’s service area.
Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente
depends on contract renewal. This contract is renewed annually by the Centers for Medicare & Medicaid
Services (CMS). By law, our plan or CMS can choose not to renew our Medicare contract.
For information about Original Medicare, refer to your “Medicare & You” handbook. You can view it
online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048.
2022 Summary of Benefits
July 1, 2022 –June 30, 2023
Kaiser Permanente Senior Advantage (HMO) Benefit Chart
With Medicare Part D prescription drug coverage
This document is a summary. It doesn’t include everything about what’s covered and not covered
or all the plan rules. For details, see the Evidence of Coverage (EOC), which we’ll send
you after you enroll. For questions on your coverage, please contact Member Services
at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., seven days a week.
What’s covered and what it costs
*Your plan provider may need to provide a referral
y Prior authorization may be required
Kaiser Permanente Senior Advantage (HMO) Group plan for RCUH – Medicare Retirees
Benefits and premiums You pay
Monthly plan premium
Your group will notify you if you are required to contribute to your
group’s premium. If you have any questions about your contribution
toward your group’s premium and how to pay it, please contact your
group’s benefits administrator.
Deductible None
Your maximum out-ofpocket
responsibility
Doesn’t include Medicare Part D drugs.
$2,500
Inpatient hospital coverage *y
There is no limit to the number of medically
necessary inpatient hospital days.
$50 copay per day for days 1 through 6.
$0 per day for days 7 and beyond
Outpatient hospital coverage *y $50 per visit
Ambulatory Surgery Center *y $50 per visit
Doctor’s visits
Primary care providers $15 per visit
Specialists *y $15 per visit
Preventive care*
See the EOC for details. $0
Benefits and premiums You pay
Emergency care
We cover emergency care anywhere in the
world.
$90 per Emergency Department visit
Urgently needed services
We cover urgent care anywhere in the world. $20 per office visit
Diagnostic services, lab, and imaging *y
Lab tests $0
Diagnostic tests and
procedures (like EKGs and ultrasounds)
$0
X-rays $15 per X-ray
MRI, CT and PET $20 per test
Hearing services * y
Exams to diagnose and treat
hearing and balance issues
Routine hearing exams
$15 per visit
Hearing aids (up to 2 hearing aid(s) every
36 months)
60% of applicable charges for lowest priced model
Vision services *
Visits to diagnose and treat eye diseases
and conditions
$15 per visit
Routine eye exams $15 per visit
Eyeglasses or contact lenses after
cataract surgery
20% coinsurance up to Medicare’s limit and you pay
any amounts beyond that limit.
Mental health services *y
Outpatient group therapy $15 per visit
Outpatient individual therapy $15 per visit
Skilled Nursing Facility * y Per benefit period:
We cover up to 100 days per
benefit period
$0 per day for days 1 through 20
$50 per day for days 21 through 100
Physical therapy * y $15 per visit
Ambulance 20% coinsurance per one-way trip
Transportation Not covered
Benefits and premiums You pay
Medicare Part B drugs y
A limited number of Medicare Part B drugs
are covered when you get them from a plan
provider (see the EOC for details.)
Drugs that must be
administered by a health
care professional
20% coinsurance
Up to a 30-day supply from a plan
pharmacy
$10 for generic drugs
$45 for brand-name drugs
Alternative Medicine, dental, and optical riders will be attached at the end if applicable.
Part D prescription drug coverage y
For details on what you pay for your Part D prescription drugs through our plan, see the ”Medical
Benefits Chart (what is covered and what you pay)”, Chapter 5, and Chapter 6 in the Evidence of
Coverage (EOC).
Initial Coverage Stage
Drug Tier Retail Plan Pharmacy Mail-order Plan Pharmacy
(Up to a 90-day supply)**
Tier 1 (Preferred generic) $3 (up to a 30-day supply) $0
Tier 2 (Generic) $10 (up to a 30-day supply) Two times the listed copay
Tier 3 (Preferred brand-name) $45 (up to a 30-day supply) Two times the listed copay
Tier 4 (Nonpreferred brand-name) $45 (up to a 30-day supply) Two times the listed copay
Tier 5 (Specialty) $200 (up to a 30-day supply) $200 (up to a 30-day supply)
Tier 6 (Vaccines) $0 Not applicable
**Note: Coverage is limited in certain situations and some drugs may not be eligible for mailing and/or
mail order discount.
After your initial Coverage Stage, there is a Catastrophic Coverage Stage. This stage is generally for people with high drug costs. Most members do not reach the Catastrophic Coverage Stage.
For information about your costs in these stages, see the ”Medical Benefits Chart (what is covered
and what you pay)”, Chapter 5, and Chapter 6 in the Evidence of Coverage (EOC)
Summary of Dental Benefits
Kaiser Permanente Senior Advantage (HMO) Basic – Group No. 8295
Effective: 01/01/2021
This summary is a brief description of a Hawaii Dental Service (HDS) member’s dental benefits. Some limitations, restrictions, and exclusions may apply. Plan benefits are governed by the provisions detailed in the KFPHI agreement with HDS, HDS’s Procedure Code Guidelines and Delta Dental National Policies when applicable. Certain provisions may vary across group agreements such as waiting periods, frequency and age limitations, etc. and may not be included in this summary. For additional information, please contact HDS Customer Service.
You must receive services from an HDS Medicare Advantage network dentist for HDS to pay for the covered benefits listed below in the table. All dental claims must be filed within 12 months of the date of service to be eligible for HDS claims payment.
If you receive services from a dentist that doesn’t participate in the HDS Medicare Advantage network, the services are not covered by the plan and you will be responsible for the full cost of the services.
For the list of network dentists, see the Provider Directory, visit hawaiidentalservice.com or call HDS customer service at 529-9248 or toll-free 1-844-379-4325 (Monday through Friday, 7:30 a.m. to 4:30 p.m.).
PLAN MAXIMUM The most HDS will pay for each person for all covered dental services performed during the plan year.
Plan Maximum
None
DIAGNOSTIC
HDS PLAN PAYS
Examinations 100% 2x/yr
Bitewing X-rays 100% 1x/yr
Other X-rays 70% Full mouth X-rays 1x/5 yrs
PREVENTIVE
Cleanings 100% 2x/yr
OTHER SERVICES
Adjunctive General Services 70%
Emergency Treatment of Dental Pain (Palliative Treatment) Once per visit per dental office for relief of pain but not to cure 70%
2021_8295 Kaiser Permanente Senior Advantage (HMO) Basic
Kaiser Foundation Health Plan, Inc. –Hawaii
Alternative Medicine Rider C –20 visits / $20
This rider is included in the Benefit Summary in the front of the Guide to Your Health Plan (Guide).
The provisions of this Guide and the Evidence of Coverage (EOC) apply to this rider.
For Senior Advantage members, this rider is included in the Medical Benefits Chart in the front of
the Evidence of Coverage (EOC).
The following becomes part of the Benefit Summary in the front of this Guide.
Benefits You pay
Alternative
medicine
rider C
Chiropractic and Acupuncture services
Up to a maximum of 20 office visits per calendar year.
This rider does not cover services which are performed or
prescribed by a Kaiser Permanente physician or other
Kaiser Permanente health care provider. Services must be
performed and received from Participating Chiropractors and
Participating Acupuncturists of American Specialty Health
(ASH). Covered Services include:
$20 copayment
per office visit
Chiropractic services for the treatment or diagnosis of Neuromusculo-skeletal
Disorders which are authorized by ASH and performed by a Participating Chiropractor.
Acupuncture services for the treatment or diagnosis of Neuromusculo-skeletal
Disorders, Nausea or Pain Syndromes which are authorized by ASH and performed by a
Participating Acupuncturist.
Adjunctive therapy as set forth in a treatment plan approved by ASH, which may
involve chiropractic modalities such as ultrasound, hot packs, cold packs, electrical
muscle stimulation and other therapies.
Diagnostic tests are limited to those required for further evaluation of the Member’s
condition and listed on the payor summary and fee schedule. Medically necessary
x-rays, radiologic consultations, and clinical laboratory studies must be performed by
either an appropriately certified Participating Chiropractor or staff member or referred to
a facility that has been credentialed to meet the criteria of ASH. Diagnostic tests must be
performed or ordered by a Participating Chiropractor and authorized by ASH.
Chiropractic appliances when prescribed and provided by a
Participating Chiropractor and authorized by ASH.
Payable up to a maximum of $50 per calendar year
The following is added to Chapter 3: Benefit Description
Alternative Medicine Rider
• This Alternative Medicine rider does not cover Services which are performed or prescribed by
a Hawaii Permanente Medical Group (herein referred to as ”HPMG”) physician, but instead
refer to services performed or prescribed by a Health Plan Designated Network.s Participating
Chiropractor or Participating Acupuncturist. Medically necessary services performed or
prescribed by a Hawaii Permanente Medical Group physician are covered in accordance with
this EOC, to the extent the provider is acting within the scope of the provider.s license or
certification under applicable state law.
• Alternative medicine services are provided as described in this rider. Alternative medicine
services listed in this rider are covered only if Medically Necessary and received from the
Health Plan Designated Network’s (herein referred to as ”Designated Network”) Participating
Chiropractors and Participating Acupuncturists.
• The Designated Network, Participating Chiropractors, Participating Acupuncturists, HPMG,
Kaiser Foundation Health Plan, Inc. (herein referred to as ”Health Plan”), and Kaiser
Foundation Hospitals are independent contractors. Health Plan, Kaiser Foundation Hospitals,
HPMG and its Physicians shall not be liable for any claim or demand on account of damages
arising out of or in any manner connected with any injuries suffered by Members while
receiving Chiropractic or Acupuncture Services. The Designated Network and Participating
Chiropractors and Participating Acupuncturists are not agents or employees of Health Plan.
Neither Health Plan nor any employee of Health Plan is an employee or agent of the
Designated Network or Participating Chiropractors or Participating Acupuncturists.
Participating Chiropractors and Participating Acupuncturists maintain the chiropractor-patient
and the acupuncturist-patient relationship with Members and are solely responsible to
Members for all Chiropractic or Acupuncture Services under this rider.
Definitions
As used in this rider, the terms in boldface type, when capitalized, have the meaning shown:
• Acupuncture Services: Acupuncture Services are Services rendered or made available to a
Member by a Participating Acupuncturist for treatment or diagnosis of Neuromusculo-skeletal
Disorders, Nausea or Pain Syndromes.
• Chiropractic Appliances: Chiropractic Appliances are support type devices prescribed by a
Participating Chiropractor. These shall be restricted to the following items to the exclusion of
all others: elbow supports, back supports (thoracic), cervical collars, cervical pillows, heel lifts,
hot or cold packs, support/lumbar braces/supports, lumbar cushions, orthotics, wrist supports,
rib belts, home traction units (cervical or lumbar), ankle braces, knee braces, rib supports and
wrist braces.
• Chiropractic Services: Chiropractic Services are services rendered or made available to a
Member by a Participating Chiropractor for treatment or diagnosis of Neuromusculo-skeletal
Disorders.
• Chiropractic and Acupuncture Urgent Office Visits: Chiropractic and Acupuncture Urgent
Office Visits are Covered Services received in a Participating Chiropractor’s office and
rendered for the sudden unexpected onset of an injury or condition affecting the
neuromuscular-skeletal system which manifests itself by acute symptoms of sufficient
severity, including severe pain, which delay of immediate chiropractic or acupuncture attention
could decrease the likelihood of maximum recovery.
• Copayments: Payments to be collected directly by a Participating Chiropractor or
Participating Acupuncturist from a Member for Covered Services.
• Covered Services: Covered Services are Chiropractic Services and/or Acupuncture
Services as described in this rider that are Medically Necessary Services.
• Designated Network: American Specialty Health, Inc.
• Experimental or Investigational: The Designated Network classifies a chiropractic or
acupuncture service as experimental or investigational if the chiropractic or acupuncture
service is investigatory or an unproven procedure or treatment regimen that does not meet
professionally recognized standards of practice.
• Medically Necessary Services: Medically Necessary Services are Chiropractic Services
and/or Acupuncture Services which are:
– Necessary for the treatment of Neuromusculo-skeletal Disorders; Pain Syndromes
(acupuncture only); or Nausea (acupuncture only);
– Established as safe and effective and furnished in accordance with professionally
recognized standards of practice for chiropractic or acupuncture.
– Appropriate for the symptoms, consistent with the diagnosis, and otherwise in
accordance with professionally recognized standards of practice; and
– Pre-authorized by the Designated Network, except for an initial examination by a
Participating Chiropractor and/or Participating Acupuncturist.
• Nausea: Nausea is an unpleasant sensation in the abdominal region associated with the
desire to vomit that may be appropriately treated by a Participating Acupuncturist in
accordance with professionally recognized standards of practice and includes post-operative
nausea and vomiting, chemotherapy nausea and vomiting, and nausea of pregnancy.
• Neuromusculo-skeletal Disorders: Neuromusculo-skeletal Disorders are conditions with
associated signs and symptoms related to the nervous, muscular and/or skeletal systems.
Neuromusculo-skeletal Disorders are conditions typically categorized as structural,
degenerative or inflammatory disorders, or biomechanical dysfunction of the joints of the body
and/or related components of the motor unit (muscles, tendons, fascia, nerves,
ligaments/capsules, discs and synovial structures) and related to neurological manifestations
or conditions.
• Pain Syndromes. Pain Syndromes mean a sensation of hurting or strong discomfort in some
part of the body caused by an injury, illness, disease, functional disorder, or condition.
• Participating Acupuncturist: A Participating Acupuncturist is an acupuncturist duly licensed
to practice acupuncture in the State of Hawaii and who has entered into an agreement with
Designated Network to provide Covered Services to Members.
• Participating Chiropractor: A Participating Chiropractor is a chiropractor duly licensed to
practice chiropractic in the State of Hawaii and who has entered into an agreement with
Designated Network to provide Covered Services to Members.
Services and Benefits
• Except for the initial examination by a Participating Chiropractor, Covered Services are limited
to Chiropractic Services for the treatment or diagnosis of Neuromusculo-skeletal Disorders
which are authorized and performed by a Participating Chiropractor.
• Except for the initial examination by a Participating Acupuncturist, Covered Services are
limited to Acupuncture Services for the treatment or diagnosis of Neuromusculo-skeletal
Disorders, Nausea or Pain Syndromes which are authorized and performed by a Participating
Acupuncturist.
• Office Visits.
– Each visit to a Participating Chiropractor or Participating Acupuncturist requires a
Copayment as stated in the above Benefit Summary, which Members pay at the time of
the visit. Members are entitled up to a combined maximum of visits per calendar year as
stated in the above Benefit Summary.
– Initial examination with a Participating Chiropractor or a Participating Acupuncturist to
determine the problem, and if Covered Services appear warranted, to prepare a
treatment plan of services to be furnished. One initial exam will be provided for each new
condition.
– Subsequent office visits which are described in a treatment plan approved by the
Designated Network which may involve manipulations, adjustments, therapy, and
diagnostic tests listed below.
– Reevaluation. During a subsequent office visit prescribed in the treatment plan or a
separate visit, when necessary, the Participating Chiropractor or Participating
Acupuncturist may perform a reevaluation examination to assess the need to continue,
discontinue or modify the treatment plan.
– Chiropractic or Acupuncture Urgent Office Visits.
• Diagnostic tests for Chiropractic. Diagnotci tests are limited to those required for further
evaluation of the Member’s condition and listed on the payor summary and fee schedule.
Medically necessary x-rays, radiological consultations, and clinical laboratory studies must be
performed by either a Participating Chiropractor, who is acting within the scope of their license
or certification under applicable state law, or staff member or referred to a facility that has
been credentialed to meet the criteria of the Designated Network. Diagnostic tests must be
performed or ordered by a Participating Chiropractor and authorized by the Designated
Network.
• Chiropractic Appliances. Chiropractic Appliances must be prescribed by a Participating
Chiropractor and authorized by the Designated Network.
• Adjunctive Therapy. Adjunctive therapy, as set forth in a treatment plan approved by
Designated Network, may involve chiropractic modalities (such as ultrasound, hot packs, cold
packs, and electrical muscle stimulation), acupuncture therapies (such as acupressure,
moxibustion, and cupping), and other therapies.
The following amends part of Chapter 4: Services Not Covered
Acupuncture: You are not covered for Services and supplies related to acupuncture, except as
described in this rider.
Chiropractic Services: You are not covered for Services of chiropractors or chiropractic Services,
except as described in this rider.
The exclusions and limitations listed in Chapter 4: Services Not Covered apply to this rider. The
following exclusions and limitations also apply:
• Any Chiropractic service or treatment not furnished by a Participating Chiropractor and not
provided in the Participating Chiropractor’s office.
• Any Acupuncture service or treatment not furnished by a Participating Acupuncturist and not
provided in the Participating Acupuncturist’s office.
• Examination and/or treatment of conditions other than Neuromusculo-skeletal Disorders from
Participating Chiropractors, or Neuromusculo-skeletal Disorders, Nausea, or Pain Syndromes
from Participating Acupuncturists.
• Services, lab tests, x-rays and other treatments not documented as medically necessary or as
appropriate.
• Services, lab tests, x-rays and other treatments classified as experimental or investigational.
• Diagnostic scanning and advanced radiographic imaging, including Magnetic Resonance
Imaging (MRI), CAT scans, and/or other types of diagnostic scanning or therapeutic radiology;
thermography; bone scans, nuclear radiology, any diagnostic radiology other than plain film
studies.
• Alternative medical services not accepted by standard allopathic medical practices including,
but not limited to, acupuncture, hypnotherapy, behavior training, sleep therapy, weight
programs, massage therapy, lomi lomi, educational programs, naturopathy, podiatry, rest
cure, aroma therapy, osteopathy, non-medical self-care or self-help, or any self-help physical
exercise training, or any related diagnostic testing.
• Vitamins, minerals, nutritional supplements, botanicals, ayurvedic supplements, homeopathic
remedies or other similar-type products.
• Nutritional supplements which are Native American, South American, European, or of any
other origin.
• Traditional Chinese herbal supplements.
• Nutritional supplements obtained by Members through a health food store, grocery store or by
any other means.
• Prescriptive and non-prescriptive drugs, injectables and medications.
• Transportation costs, such as ambulance charges.
• Hospitalization, manipulation under anesthesia, anesthesia or other related services.
• Diagnostic tests, laboratory services and tests for Acupuncture.
• Services or treatment for pre-employment physicals or vocational rehabilitation.
• Any services or treatments caused by or arising out of the course of employment or covered
under any public liability insurance.
• Air conditioners, air purifiers, therapeutic mattresses, supplies or any other similar devices or
appliances; all chiropractic appliances (except as covered in this rider) or durable medical
equipment.
• Services provided by a chiropractor or acupuncturist outside the State of Hawaii.
• All auxiliary aids and services, such as interpreters, transcription services, written materials,
telecommunications devices, telephone handset amplifiers, television decoders, and
telephones
compatible with hearing aids.
• Adjunctive therapy not associated with acupuncture or chiropractic services.
• Services and/or treatment which are not documented as Medically Necessary services.
• Any services or treatment not authorized by ASH, except for an initial examination.
• Any office visits beyond the maximum limit (stated in the Benefit Summary) per calendar year.
What you need to know about your alternative medicine benefits
1. Do I need to see my Kaiser Permanente physician to obtain a referral for a Participating
Chiropractor or Participating Acupuncturist?
No. These alternative medicine services do not require a Kaiser Permanente physician’s
approval.
2. How do I choose a Participating Chiropractor or Participating Acupuncturist?
You may select a Participating Chiropractor or Participating Acupuncturist who participates
with ASH. You may obtain a list with their addresses and phone numbers by calling the Kaiser
Permanente Member Services Department at 1-800-966-5955. You may also view the list by
logging on to our website at www.kp.org.
3. Will an X-ray be covered if it is ordered by the Participating Chiropractor and performed
at a Kaiser Permanente location?
Only medically necessary X-rays authorized by ASH are covered. The X-rays must be
performed in either a Participating Chiropractor’s office or an ASH participating ancillary
provider’s office in order to be covered.
4. How do I obtain chiropractic or acupuncture services in Hawaii?
Simply select a Participating Chiropractor or Participating Acupuncturist and call to set-up an
appointment. At your appointment, present your Kaiser Foundation Health Plan membership
information card and pay your designated copayment.
85812_KAH6166 1/2022
kp.org/medicare
Kaiser Foundation Health Plan, Inc.
711 Kapiolani Blvd.
Honolulu, HI 96813
Kaiser Foundation Health Plan, Inc., Hawaii Region.
A nonprofit corporation and Health Maintenance Organization (HMO)
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